Passive transfer of SARS-CoV-2 antibodies with platelet transfusions.

BACKGROUND: Although over 5000 platelet transfusions occur daily in the United States, the presence of SARS-CoV-2 antibodies in platelet units is not commonly evaluated for. The effects of platelet transfusions with SARS-CoV-2 antibodies remain largely unknown. We evaluated single-donor (apheresis) platelet units for SARS-CoV-2 antibodies and determined if platelet transfusions passively transferred antibodies to seronegative recipients. STUDY DESIGN AND METHODS: We conducted a retrospective analysis as part of a quality assurance initiative during February to March 2021 at a tertiary referral academic center in suburban New York. Platelet units and platelet recipients were evaluated for the presence of SARS-CoV-2 antibodies using the DiaSorin LIASON SARS-CoV-2 S1/S2 IgG assay. There were 47 platelet recipients eligible for study inclusion. The primary outcome was the presence of SARS-CoV-2 spike protein IgG antibodies in the recipient's blood after platelet transfusion. RESULTS: Twenty-three patients received platelets with SARS-CoV-2 spike protein IgG antibodies; 13 recipients had detection of SARS-COV-2 antibodies (56.5%), and 10 recipients did not. The median antibody titer in the platelet units given to the group with passive antibodies detected was significantly higher compared to the median antibody titer in the platelet units given to the group without antibodies detected (median [interquartile range]: 306 AU/ml [132, 400] vs. 96.1 AU/ml [30.6, 186], p = .027). CONCLUSIONS: Our study demonstrated a significant rate of passive transfer of SARS-CoV-2 spike protein IgG antibodies through platelet transfusions. Considering the volume of daily platelet transfusions, this is something all clinicians should be aware of.

Critical conversations on patient blood management with clinical colleagues.

Although a subspecialty-trained transfusion medicine (TM) physician brings value to the clinical bedside, hospital transfusion service oversight often falls under the responsibility of pathologists primarily focused on surgical pathology. Yet, pathologists who lack TM fellowship training may not be quite as confident in their role as the TM physician in-charge, especially when the need to communicate with another clinician arises. Given that blood is a resource subject to frequent shortages, there is a need for constant monitoring of blood utilization such that those responsible for transfusion service oversight need to handle challenging clinical interactions when transfusion guidelines are breeched. Generally, the average pathologist is more knowledgeable regarding blood component therapy than other clinician. Yet, disagreements concerning patient transfusion management can arise, in spite of established evidence-based hospital transfusion guidelines. Since authoritative fact stating is not likely to be effective in changing the entrenched practices, pathologists must engage in strategies that will develop meaningful working relationships with their clinical colleagues. Such strategies include being a visible part of direct patient care, such as attendance at patient rounds or provision of mini-consultations by phone regarding transfusion management. Inviting clinicians to attend the hospital transfusion committee meetings and scheduling educational grand rounds are also useful strategies. Clinicians may be more receptive to blood conservation during times of shortages if open communication is established, particularly if hospital leadership is involved in urgent crisis messaging to the clinicians and other hospital staff involved in patient care.

How do I manage O- red blood cell inventory.

Currently there are no widely accepted guidelines regarding the appropriate use of O- red blood cells (RBCs). Although there has been a decline in overall RBC utilization since 2010, the use of O- RBCs has continued to proportionally increase over this time period resulting in frequent shortages. When faced with these shortages, we implemented some simple strategies that resulted in a significant decrease in annual O- RBC utilization from 10% to 7.5% despite an increase in total RBC utilization. These strategies included collaboration with the clinical staff, improving practices within the blood bank, and having our health system partner with our blood supplier. Herein, we detail our strategies for hospital transfusion services to improve O- RBC utilization. Most of these can be easily implemented and do not require additional resources.

Liquid plasma use during "super" massive transfusion protocol.

BACKGROUND: A massive transfusion protocol (MTP) presents a logistical challenge for most blood banks and trauma centers. We compare the ratio of packed red blood cells (PRBC) and plasma transfused over serial time points in those requiring MTP (10-30 U PRBC/24 h) to those requiring "super" MTP (S-MTP; >30 U PRBC/24 h) and test the hypothesis that changes in allocation of blood products with use of readily transfusable liquid plasma (LP) improves the ratio of PRBC and plasma during S-MTP. MATERIALS AND METHODS: All transfused trauma patients (n = 1305) from January 01, 2009-April, 03, 2015 were reviewed. PRBC:plasma ratio was compared for MTP (n = 277) and S-MTP (n = 61) patients, before and after the availability of LP at our institution. Data are reported as mean ± standard deviation or median (interquartile range). RESULTS: Age was 41 ± 19 y, 52% blunt mechanism, injury severity score 32 ± 16, and 46.3% mortality. In 24 h, requirements were 17 (14) U PRBC and 10 (11) U plasma, with a PRBC:plasma of 1.6 (0.8). Within the first hour, PRBC:plasma for S-MTP versus MTP was 2.1:1 versus 1.7:1 (P = 0.017). With LP, S-MTP patients received significantly lower PRBC:plasma at the first hour (P < 0.001). Before institutional changes, PRBC:plasma positively correlated with PRBC transfused at hour 1 (r = 0.410, R(2) = 0.168, P < 0.001); after institutional changes and the advent of LP, there was no correlation (r = 0.177, R(2) = 0.031, P = 0.219). CONCLUSIONS: Within the first hour of transfusion, units of PRBC transfused positively correlated with PRBC:plasma, and patients receiving S-MTP had higher PRBC:plasma than those receiving MTP. Changes in our institution's MTP protocol to include LP improved the early PRBC:plasma transfused in patients requiring S-MTP.

Microparticles in stored red blood cells as potential mediators of transfusion complications.

This article reviews evidence for the involvement of cell-derived microparticles (MPs) in transfusion-related adverse events. The controversy concerning possible added risk of older versus fresher stored blood is also reviewed and is consistent with the hypothesis that MPs are involved with adverse events. Although all types of circulating MPs are discussed, the emphasis is on red blood cell-derived MPs (RMPs). The evidence is particularly strong for involvement of RMPs in transfusion-related acute lung injury, but also for postoperative thrombosis. However, this evidence is largely circumstantial. Work in progress to directly test the hypothesis is also briefly reviewed.

Cellular volume and marker expression in human peripheral blood apheresis stem cells.

Coulter volume is far more accurate measure of cell volume than forward angle light scatter. In this report, we have used Coulter volume to determine the mean cell volume and diameter of normal human peripheral blood cells and hematopoietic progenitor cells obtained by apheresis (HPC-A) from patients with hematological malignancies. Fresh peripheral blood samples (treated with Beckman Coulter IMMUNOPrep erythrocyte lysis solution), HPC-A samples (treated with BD Biosciences FACSLysing solution), or processed by Ficoll Hypaque sedimentation method were stained with CD45-FITC and PE-labeled CD34, CD90, CD117, and CD133 antibodies and analyzed for electronic volume and two color fluorescence. The mean electronic volume and diameter of mononuclear cells from fresh peripheral blood samples prepared with IMMUNOPrep were lymphocytes (191 microm(3), 7.16 microm), monocytes (370 microm(3), 9.91 microm), and granulocytes (328 microm(3), 8.56 microm). In mononuclear cells of HPC-A samples prepared by Histopaque-1077 sedimentation, the lymphocytes had volume and diameter of 311 microm(3), 8.4 microm, monocytes were 486 microm(3), 9.76 microm, and granulocytes were 515 microm(3), 9.95 microm. In contrast, HPC-A samples prepared after lysis with FACSLysing solution had mean electronic volume and diameter of lymphocytes (414 microm(3), 9.25 microm), monocytes (797 microm(3), 11.5 microm), and granulocytes (670 microm(3), 10.85 microm). Cell volume of mononuclear cells in the HPC-A samples prepared by Histopaque-1077 sedimentation method was correlated with the expression of stem cell markers CD34, CD90, CD117, and CD133. CD90 positive cells had the smallest mean electronic volume of 299.93 microm(3) when compared with cells with positive expression of CD133 (322 microm(3)), CD117 (349 microm(3)), CD34 (407 microm(3)), and CD45 (453 microm(3)). Correlation of cell volume with stem cell marker expression may allow for the identification of small stem cells, which may not express the conventional markers used for the identification of stem cells in HPC-A samples.

Alloimmunization to red cell antigens in liver and multivisceral transplant patients.

BACKGROUND: Alloimmunization to red blood cell (RBC) antigens can significantly impact transfusion support of patients undergoing solid-organ transplantation. This study evaluated the incidence of clinically significant RBC alloantibodies (abs) in 2000 consecutive adults receiving liver (OLTX), intestinal (ITX) or multivisceral (MVT) transplants. METHODS: From January 1991 to May 2006, 2000 patients underwent OLTX (n=1892), MVT (n=74), or ITX (n=34). Blood sample for serologic investigation was submitted to the transfusion service no later than 4 hr before surgery. The presence of clinically significant RBC abs before transplant with subsequent transfusion requirements, the incidence of delayed transfusion reactions, and de novo abs after transplant were evaluated. RESULTS: One hundred fifteen patients (5.75%) had clinically significant RBC abs before transplant, with 56.7% directed against Rh system antigens. Forty-six (40%) had multiple abs. A mean of 18 packed RBC units (U) were transfused per patient. Patients requiring >20 U (n=34) or those with multiple abs received antigen-negative units for the first 5-10 U when antibody was still present, switched to antigen-unscreened units during massive blood loss and returned to antigen-negative units for the last 5-10 U transfused. Twelve patients (0.6%) developed de novo abs posttransplant. Twenty-two (1.1%) had delayed serologic transfusion reaction. All patients were successfully managed without delay in initiation of surgery or hemolytic complications. CONCLUSION: RBC alloimmunization can present a special challenge to solid-organ transplantation. Early serologic testing of the recipient pretransplant and prompt communication between the transfusion service and transplant team facilitates successful transfusion management of these patients.

A Case of Hemolytic Disease of the Newborn due to Di (a) Antibody.

Anti-Di(a) is a clinically significant red cell antibody known to cause hemolytic disease of the newborn. Here, we report on a case of mild hemolytic disease of the newborn caused by Di(a) antibody. The mother had three prior pregnancies with no history of blood transfusion. She delivered a preterm 35-week-old female newborn by cesarean section. The neonate developed anemia and mild icterus on postnatal day five with hemoglobin of 9500 mg/dL and total bilirubin of 10 mg/dL. The direct antiglobulin test on the neonate's red blood cells was positive. The maternal serum and an eluate from the infant RBCs were negative in routine antibody detection tests but were positive using commercially prepared Di(a+) red cells. The neonate was discharged home in stable condition following treatment with erythropoietin and phototherapy. When a newborn has a positive DAT in the absence of major blood group incompatibility or commonly detected RBC antibodies, an antibody to a low frequency antigen such as Di(a) must be considered. Further immunohematology tests are required to determine presence of the antibody and the clinician must be alerted to closely monitor the infant for signs of anemia and hemolysis.

Initial hematocrit predicts the use of blood transfusion in the pediatric trauma patient.

PURPOSE: Initial hematocrit (Hct) is generally not considered a marker of acute blood loss because it is assumed that physiologic response of fluid conservation to hemorrhage is delayed. We challenged this idea by theorizing that admission Hct correlates with conventional signs of shock and predicts the use of blood transfusion during resuscitation of pediatric trauma patients. METHODS: Data from 1928 pediatric admissions (<18 years) at a Level I trauma center (2000-2012) were compared using standard statistical analyses and logistic regression modeling to identify factors associated with blood transfusion during initial trauma resuscitation. RESULTS: Overall mortality rate was 3.5%, with a transfusion rate of 10.7%. Factors significantly associated with transfusion were initial Hct, Glasgow Coma Score, base deficit, and injury severity score (all p<0.001). Initial Hct is a stronger predictor for transfusion (area under receiver operator curve (AUC: 0.728) compared to age-specific tachycardia (AUC: 0.689), age-specific hypotension (AUC: 0.673), and altered mental status (AUC: 0.654)). On multivariate analysis, initial Hct was an independent predictor (OR [95% CI]: 2.94 [1.56, 5.52]) along with hypotension (6.37 [2.95, 13.8]), base deficit (4.14 [1.38, 12.4]), and tachycardia (3.07 [1.62, 5.81]). CONCLUSIONS: Initial Hct correlates significantly with conventional signs of shock and is a strong independent predictor for blood transfusion with better predictability than other clinical factors.

Electronic volume, aldehyde dehydrogenase, and stem cell marker expression in cells from human peripheral blood apheresis samples.

BACKGROUND: Over-expression of aldehyde dehydrogenase and other stem cell markers is characteristic of cells with tumorigenic potential in NOD/SCID mice. Most of these studies have focused on metastatic cells in bone marrow and on solid tumors. There are no studies on correlation of marker expression with ALDH1 expression in cells from human peripheral blood apheresis (HPC-A) samples. METHODS: HPC-A samples from 44 patients were incubated with Aldefluor with or without the presence of aldehyde dehydrogenase inhibitor DEAB. Cells with high aldehyde dehydrogenase expression (ALDH1(bright)) were analyzed for stem/progenitor markers CD34, CD90, CD117, and CD133. Electronic volume measured by Coulter principal in a Quanta flow analyzer was correlated with ALDH1 and marker expression. RESULTS: In ALDH1(bright)/SSC(low) cells, 0.13% of the cells had CD34(+) expression and three distinct populations were seen. Expression of CD90 was dim and the frequency of ALDH1(bright)/SSC(low)/CD90(dim) cells amongst the nonlineage depleted samples was 0.04%. CD117(dim-bright) expression was seen in 0.17% of the samples. Three distinct populations of cells with CD133 expression were seen in ALDH1(bright)/SSC(low) nonlineage depleted cells with a frequency of 0.28%. The ALDH1(bright)/CD90(dim) cells had the smallest mean electronic volume of 264.9 microm(3) when compared with cells with CD34(bright) expression (270.2 microm(3)) and ALDH1(dim)/CD90(dim) cells (223 microm(3)). CONCLUSIONS: ALDH1(bright)/SSC(low) cells show heterogeneity in expression of the four stem cell markers studied. The CD90 cells in both the ALDH1(bright) and ALDH1(dim) populations had the smallest mean electronic volume when compared with similar cells with CD117 expression.

Concurrent thrombotic thrombocytopenic purpura and immune thrombocytopenic purpura in a patient with metastatic neuroendocrine tumour successfully treated with rituximab-CVP.

We report a case of concurrent thrombotic thrombocytopenic purpura (TTP) and immune thrombocytopenic purpura (ITP) in a 63-year-old woman who had been receiving treatment with bevacizumab for metastatic neuroendocrine tumour (NET). At diagnosis, she had severe anaemia and thrombocytopenia with elevated lactate dehydrogenase and many schistocytes on the peripheral blood smear. She was treated with frequent fresh frozen plasma infusions and plasmapheresis with poor response. Later, she was found to have platelet surface glycoprotein antibodies in the serum and received four cycles of rituximab, vincristine, cyclophosphamide (rituximab-CVP) and steroids in addition to plasma therapy. The haemoglobin and platelet counts improved. To our knowledge, this is the first reported case of concurrent TTP and ITP in a patient with metastatic NET diagnosed while receiving bevacizumab therapy, who was successfully treated with the combination of rituximab, vincristine, cyclophosphamide and steroids.

Electronic volume of CD34 positive cells from peripheral blood apheresis samples.

BACKGROUND: The authors have used a flow analyzer to measure electronic cellular volume of peripheral blood hematopoietic stem/progenitor cells obtained by granulocyte-colony stimulating factor (G-CSF) mobilization and apheresis (HPC-A) of patients with hematological malignancies. METHODS: Fifty three apheresis samples stained with CD45-fluorescein isothiocyanate (FITC) and CD34-R-phycoerythrin (PE)-labeled antibodies after erythrocyte lysis with BD FACS Lysing Solution were analyzed for electronic cell volume and two-color FITC and PE fluorescence. RESULTS: Lymphocytes, monocytes and granulocytes in the HPC-A samples had a mean electronic volume of 414, 797, and 670 microm(3), respectively corresponding to cell diameter of 9.25, 11.5, and 10.85 microm. In 53 HPC-A samples analyzed, the mean electronic volume of the CD34 positive mononuclear cells was 407 microm(3) while the CD45 positive cells had mean volume of 453 microm(3). CONCLUSIONS: CD34 positive stem/progenitor cells have a smaller volume and diameter than CD45 positive mononuclear cells in HPC-A samples. In the present study the CD34 stem/progenitor cells had a considerably larger diameter than that of stem cells previously reported in the literature. With the availability of electronic cell volume as a parameter in flow cytometric analysis, further studies can be carried out to correlate stem cell volume with specific phenotypic marker expression.

Effect of plasma exchange on cytokines measured by multianalyte bead array in thrombotic thrombocytopenic purpura.

The serum cytokine profile in thrombotic thrombocytopenic purpura (TTP) has not been extensively characterized. In this pilot study, a novel technique was utilized to evaluate multiple cytokines in patients with idiopathic TTP during a course of plasma exchange (PE). Single serum samples were obtained from five TTP patients before and after each PE. Random sera were obtained from nine healthy volunteers who served as controls. The samples were evaluated for 13 cytokines (IL-1B, IL-2 , IL-4, IL-5, IL-6, IL-7, IL-8, IL-10, IL-12, IL-13, IFN-gamma, GM-CSF, and TNF-alpha) using the Luminex bead array (LINCOplex) multianalyte detection system that permits simultaneous detection of multiple cytokines from a single sample. Each patient received 4-6 PEs (Cobe Spectra) with 3.0-4.0 L of fresh frozen plasma as replacement fluid. Four of 5 patients received corticosteroids prior to and during PE. The control group did not receive steroids. Baseline values for IL-8 (182.9 vs. 6.5 pg/mL, P < 0.05) and TNF-alpha (11.4 vs. 0.9 pg/mL, P < 0.001) were significantly higher in TTP patients compared with controls. Other tested cytokines were not significantly different between the two groups. Comparison of cytokine values pre- and post-PE indicate a substantial decrease after each PE. However, cytokines rebounded to abnormal levels by the following day. There was no correlation between cytokines and serum LDH or platelet count. These findings suggest that certain cytokines, particularly IL-8 and TNF-alpha, are altered in TTP, and this may indicate a direct role in TTP pathogenesis, reflect ongoing tissue injury, or perhaps indicate an inadequate attempt to limit tissue injury.

Recurrent focal glomerulosclerosis in pediatric renal allografts: the Miami experience.

Recurrence of focal glomerulosclerosis (FSGS) following renal transplantation is a common cause of allograft loss and clinical morbidity. Recent attempts to control proteinuria and morbidity with plasmapheresis (PP) have met with limited success. Our experience with the use of mycophenolate mofetil (MMF) and angiotensin blockade (AB) in the management of refractory FSGS pre transplant suggested its potential benefit in post-transplant recurrence. This report presents our 25-year experience in pediatric renal transplantation of patients with FSGS divided into two treatment eras: Era 1-prior to use of daclizumab (anti-IL-2R) and Era 2-after daclizumab. A total of 179 pediatric patients were transplanted during the 25-year period. FSGS was confirmed in 27 (15%); 16 of 28 allografts (57%) had recurrence of FSGS during the post-transplant period. In Era 1, only 6 of 16 (38%) recurred in the allograft, while 10 of 12 (83%) recurred during Era 2. The odds ratio of recurrence of FSGS in the allograft after induction with anti-IL-2R was 8.3 (95% confidence interval=1.3-52, P =0.02). Only 2 patients in Era 1 received PP, while 10 in Era 2 were entered into an intensive PP protocol followed by maintenance with AB consisting of angiotensin receptor blockers alone, or in combination with angiotensin-converting enzyme inhibitor. Although proteinuria decreased an average of 80+/-16% with PP, the response was variable and severe morbid edema persisted in poor responders. Maximum benefit occurred with the addition of AB and MMF. After a follow-up of 27+/-15 months, proteinuria has shown a sustained decrease of 94+/-8% below baseline. In conclusion, our experience suggests that, with recurrent FSGS, a limited course of PP followed by maintenance therapy with AB and MMF improves symptoms and may preserve allograft function.